Of her 56 years as a nurse, Pearline Lee has spent the past decade at School Without Walls Senior High School in Northwest D.C. In her small office, Lee — a smiling, matronly woman — unabashedly rummages around in one of several fishbowls full of condoms she keeps around the school. She shows off one in gold foil.
"This is the Magnum," says Lee. "This is the largest condom that we have." It's also the most popular, she says. She holds up the last one in this particular bowl.
"Girls often say, 'why do the boys not pick the right size condom?' says Lee. "Guys pick this one because it deals with their macho-ism. This is a smaller size here, and the girls say this is the one they're really supposed to get!"
Lee is blunt when she talks about sexual health, including everything from abstinence to practicing safe sex. That's because her students have so many misconceptions about sexually transmitted diseases, including HIV. The most common one, she says, is 'everyone else is at risk but not me.'
Some teens think to themselves, "'it would never happen to me because I keep myself clean. And I'm not going to fool around with guys who look like they're not clean or wear clean clothes, and therefore I'm okay,'" says Lee.
From what she's seen, parents don't usually talk to their children about safe sex, and when they do, they tend to keep it short. "The discussion is, 'keep your pants zipped, your dress down,'" Lee says. "End of conversation."
Arming young people with information helps them make better choices, she adds. *Thomas, a senior at the School Without Walls, agrees.
"The nurse's office at my middle school had Band-Aids, not condoms," he says.
When the bowls of condoms first appeared, students would try to sneak a condom or two from the bowl, Thomas says. But they gradually became more comfortable. Thomas says his classmates don't talk to their parents about sex.
"I feel like health class is the number one information source," he says. "I can't speak for other schools and other kids, but at least here I know that the classes are very explicit and very direct."
Sexual health and HIV education at an earlier age
Students in Washington, D.C. start having sex earlier than their counterparts in other areas of the country, have more partners, and have higher rates of sexually transmitted diseases, according to a national survey. As a result of those findings, two years ago, the District began changing how it educates young people about HIV to try to protect them from getting the virus.
"You can't prepare the road for the child, but you can prepare the child for the road," says Diana Bruce, head of health programs at D.C. Public Schools. "Giving young people information they can use is empowering."
DCPS has significantly revamped its sex education program over the past couple of years. Now, in collaboration with the D.C. Department of Health, every traditional public high school has free condoms available and several teachers certified to answer questions about sexual health.
Last year, the D.C. Department of Health distributed approximately 1 million condoms to young people. Condoms cost 4 cents each; the cost of caring for a person with HIV is more than $350,000.
HIV, health education added to standardized tests
In 2011, D.C. became the first school district in the country to include age-appropriate questions on health, including HIV, on standardized tests.
"At the end of the day, what gets tested, gets done," says, Adam Tenner, who heads the nonprofit Metro TeenAIDS and trains teachers to talk comfortably about sex. .
Parents can excuse their children from having to answer some of the questions, but it's still a good baseline to gauge how much students know, Tenner says. The results are expected later this year.
Health education is not just about information, but also about helping young people manage their relationships more effectively, Tenner adds.
"We're clearly not talking about condoms with kindergartners," says Tenner. Rather, it's about giving students the tools to say 'no' when peer pressure to have sex can be "fierce," he says.
"Thirty-three percent of middle schoolers are already having sex by seventh grade," he says. "We can shut our eyes and ears, but that's not really helping the problem."
Teachers are trained to assume there are children with HIV in class, and to avoid stigmatizing language, according to Bruce.
"'You don't want to get HIV,'" she says, providing an example. "A simple statement that like that could seem benign by the teacher, but for the student living with HIV, that separates them and isolates them."
Teaching younger people about STDs and HIV
Keante* was 16 years old when he tested positive for HIV. He was dating an older man and started out using condoms, but under pressure, he stopped.
"Cause I was starting to trust him," he explains. "I shouldn't have trusted him."
What was worse, he says, was sitting through health class in 11th grade, almost a year after his diagnosis, and learning about how HIV is transmitted.
"But, I'm like already with this situation," he says. "It's kind of too late in the game to try and be explaining this to me now, making me feel bad. I believe if it was broken down to me, the condom would never have come off. Nobody told me this. No one."
Keante wishes someone had talked to him when he was 13, before he started having sex, so he wouldn't have to be worrying about the future.
"What's going to happen?" he wonders. "Am I going to see at least 20 or 25?"
That's why health education is not just about actions today; it's also about a lifetime of healthy choices, Tenner says. Schools have to be involved in HIV education, he adds.
"While they may not die on the watch of schools, we should still feel the stain of that blood on our hands, if we're letting them mature to adulthood without understanding how their bodies work, how to protect themselves, to make decisions about how and with whom they want to have sex," says Dr. William Barnes, who oversee the HIV program at Children's National Medical Center, which cares for the majority of HIV positive children and teens in the Metro area.
Barnes has seen an increase in numbers of young people with HIV. During the last five years, Children's averaged somewhere around 35 to 44 new cases per year. So far this year, they already have more than 50 cases.
Getting more younger people tested
In the District, approximately one-third of people infected with HIV don't know their status, according to current estimates.
"The biggest hurdle we have now is actually finding positive teens and getting them linked to care," he says. "The number of teens that don't know their diagnosis is a little frightening for us."
The District tested approximately 4,000 students in schools last year for sexually transmitted diseases, including HIV, according to the D.C. Department of Health. This year there are plans to "scale up" that effort even further, with a big push to have more charter schools participate.
"Our effort has been to make HIV testing as widely available as possible, to de-stigmatize it, and to get people to think this is something they can do on a routine basis," says DOH's Michael Kharfen.
Schools slowly increasing HIV awareness
In general, schools were slow to realize how big a problem HIV is, says Walter Smith, who heads DC Appleseed, an advocacy organization that grades the District's HIV prevention efforts.
"From the beginning, pretty uniformly, our lowest grades are from the schools," he says.
But that's slowly changing. In the most recent report card, D.C.'s traditional public schools received a B-plus. But charter schools only received a C; and they still need to significantly step up their HIV education efforts, Smith says.
Many charter schools don't have health teachers or programs in place as yet, which makes for a "lack of transparency and accountability threatens the health of children," according to the DC Appleseed report.
"The problem is we started so far behind that seeing the results from this is going to take time," Smith says.
Kharfen says approximately 30 percent of the $10 million the District spends on HIV prevention efforts is directed towards young people.
"When we talk about the end of HIV, where does that start?" says Kharfen. "That starts with our youngest generation and their opportunity to grow up with not having the disease. Young people living today, we can inoculate their future from HIV if we work with them now."
For all the improvement in HIV treatment, prevention is still the best treatment of all.
*Some people's names have been changed to protect their privacy.
[Music: "Summer" by Balmorhea from Rivers Arms]